Registration Form

Consent Statement:
We require your personal information below in order to fulfil the registration requirements for this event. We will share this information with your chosen charity (if applicible and only if you are taking part in this event to raise awareness and funds on behalf of the charity) so they can contact you regarding the event and fundraising.
In addition, we would like to use the details you provide to keep you updated about our services. Chapeau Events Ltd will only communicate with you in the way you choose and will always respect your privacy.Privacy Policy – For further details on how we use the information you provide to us, please see our Privacy Policy.Terms & Conditions – For full terms of event participation please see our T&Cs

Existing Customer?

Yes

No

Event

Title

First Name*

Surname*

Address

Postcode

Date of Birth

Phone Number*

Email*

How would you prefer to be contacted?

Sex

Height (cm)

Weight (KG)

Chest Size (for cycle jersey if applicable)

PASSPORT DETAILS (if event is outside UK)

Upload Passport Image?

Accepted file types: jpg, gif, png, pdf.

Full Name as shown on passport

Passport Number

Expiry Date

Issuing Country

Nationality

EMERGENCY CONTACT DETAILS (Next of Kin) Req'd for all events

Name

Phone Number

Relationship

INSURANCE DETAILS

(Please note: You need to provide travel insurance details if your event is outside the UK. You will not be allowed to participate without this. Please complete the details below or upload a copy of your valid insurance document. You can submit this at a later date if you haven't yet arranged it by sending to info@chapeauevents.co.uk. In addition, we would also recommend you apply for a EHIC card which is free and can be done via the following website; www.nhs.uk/ehic or at your local post office.

Upload Insurance Document?

Accepted file types: jpg, gif, png, pdf.

Name of Insurer

Policy Number

Emergency Contact/Claims Phone Number

MEDICAL INFORMATION

Have you ever suffered from any of the following conditions?

Heart problems

Yes

No

Blood Pressure Problems

Yes

No

Asthma, bronchitis or severe shortness of breath

Yes

No

Tendon, ligament or cartilage damage

Yes

No

Vertigo

Yes

No

Infectious disease

Yes

No

Eczema or skin problems

Yes

No

Diabetes

Yes

No

Epilepsy

Yes

No

Head Injuries

Yes

No

Cancer

Yes

No

Fractures or Broken Bones

Yes

No

Back Problems

Yes

No

Migraine or severe headaches

Yes

No

If you have said “yes” to any of the above conditions, please give details below:

Do you have any known allergies?

Are you currently taking any medication? (please specify the type and frequency and what it is used to treat)

Have you been hospitalised within the last two years? (please give details)

Have you ever suffered any psychiatric or mental illness?

Do you have any problems with sight, hearing or other senses? (please give details)

Are there any other medical issues you feel we should be aware of?

Do you have any special dietary requirements?

Do you have any other special requests, for example preferred rooming partner or single occupancy?

Where did you hear about us?

Please confirm if you are happy for photographs/video clips to be taken of you during the event.*

Yes

No

I agree that all information that I have given in this document and any other information provided to the Charity (if applicable) or Chapeau Events is complete and accurate to the best of my knowledge*

I Agree

Please confirm if you are happy for Chapeau Events to contact you regarding future events.

Email

SMS

Telephone

Post

I hereby confirm that I have read and understood the Terms & Conditions of this event. (T&Cs can be located by clicking T&Cs Link at the top of this page)*